When the FAA embraced Safety Management System (SMS), we all joined in with an understanding of shared responsibility, we did not consider social drivers that would ultimately result in drift. I was one of the eager adopters and brought SMS to the US Forest Service aviation community. We attended classes given by the FAA and quickly included SMS in our arsenal of defenses. We even required contract aviation companies to … Continue Reading ››
After the Parkland, Fl., school shooting February 14, 2018 the nation’s anger focused for a while on then-school resource officer Scot Peterson, who appeared to freeze outside the school while the gunman was firing. That focus has returned with a vengeance!
In our rush to judgment we rarely intend to do harm. Often, we react to incomplete or even scant information, fit it into our own mental model of how things should be and then jump to conclusions that could inflict harm.
Last week, CBS Morning News showed a film clip of a man snagging a baseball from a kid who was sitting directly in front of him. The less than 10 second clip resulted in the vilification of … Continue Reading ››
For the last century, the evolution of accident investigation can be tied to research and the scientific advancements in how we view our work systems. Three major lenses of scientific research emerge as we begin to examine key influences on accident investigation processes: Classic mid-century faith in engineering was termed, Scientific Management, which was followed by Systems Thinking and, ultimately, an emerging understanding of Complex Adaptive Systems.
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We have long struggled with trying to capture the facts associated with an accident in order to prevent the next one. This has been largely effective when applied to machines. In mechanical systems things are measurable, observable and more objective.
The information we get from people is always subjective. There are always issues of memory, shame, fear and politics that influence the ever-changing stories we tell. If you think about it, you have probably altered a story to … Continue Reading ››